AIDS and Child Health
---------------------
by Dr G Foster, Family AIDS Caring Trust, Zimbabwe
Amsterdam Homecare Conference, 20 May, 1997
"We are guilty of many errors and many faults, but our worst is
abandoning the children, neglecting the fountain of life. Many of
the things we need can wait. The Child cannot. Right now is the
time his bones are being formed, his blood is being made and his
senses are being developed. To him we cannot answer "Tomorrow".
His name is "Today"/ Her name is "Today"
Gabriella Mistral, Nobel Prize-winning poet from Chile
---
AIDS is having a profound impact on children's health. By mid-
1996, UNAIDS estimated that worldwide, there were:
3 million HIV infections in children - 9 million maternal orphans
due to AIDS.
In addition, it is likely that at least 30 million children are
living with HIV-positive parents, who are at risk of being orphaned
in the next few years.
What is AIDS doing to Child Health? I want to first discuss the
direct impact of HIV infection on children. Secondly, I want to look
at children who are not infected but affected by the indirect impact
of AIDS upon them. Finally, I want to discuss implications of the
AIDS epidemic on children. For the first part of my discussion, I
shall use country estimates published by the US Bureau of the Census
in March 1997.
DIRECT IMPACT OF HIV INFECTION ON CHILDREN
Infant Mortality Rates
AIDS has led to increased infant mortality rates, especially in
countries with severe AIDS epidemics and low non-AIDS infant and
child mortality rates. Thus the greatest impact of AIDS on child
health will be in countries in southern Africa which have lower non-
AIDS infant mortality and severe HIV epidemics, compared to
countries in eastern Africa which have less severe HIV epidemics and
higher non-AIDS infant mortality rates.
Infant mortality rates have increased due to AIDS, reversing
declines that have been occurring in many countries over the last
few decades. In 1996, IMR without AIDS would have been 51.7 per
1000; as a result of the AIDS epidemic, IMR is estimated to be 72.8,
40% higher than expected; in Zambia it is 30% higher than expected
and in Kenya and Uganda, it is nearly 20% higher.
IMR is set to worsen markedly during the next decade as the
epidemic spreads to affect more adults and through them more
children. By the year 2010, infant mortality rates are estimated to
more than double in Zimbabwe from 30 to 71 per 1000 and Botswana
from 26 to 66 per 1000. In Kenya, IMR will be 70% higher while in
Zambia, IMR will be 60% higher; in Malawi where infant deaths due to
other causes are high, AIDS mortality will inflate IMR by 40% with
similar increases in Tanzania and Uganda.
Child Mortality Rates
Two thirds of AIDS deaths among children occur among those 1-4 years
old; consequently, the AIDS epidemic impacts on child mortality
rates even more than on infant mortality rates. Once again, the
countries with the greatest impact of AIDS are those in southern
Africa with the most severe HIV epidemics and lower non-AIDS
mortality.
By 1996, CMR without AIDS was estimated in Zimbabwe to be 69.1;
with AIDS, CMR was 128.3, some 85% higher than expected; in other
words, 1 out of 8 children born would die before 5 years old; CMR in
Botswana and Zambia was 75% higher than expected without AIDS.
Kenya's CMR was 40% higher while Tanzania and Uganda's CMR was about
25% higher than expected without AIDS.
By 2010, the US Bureau of the Census estimates that about one
third of adults will be infected with HIV in Zimbabwe, Zambia,
Malawi and Botswana. HIV spread from mother to child in most African
countries is around 30% with one half of transmission occurring
post-partum due to breast-feeding. This means that some 10% of
children will acquire HIV infection from their mothers. With median
age of survival of children infected by their mothers of 21 months,
increases of the order of 100/1000 in CMR are estimated in these
four severest affected countries. In Zimbabwe, without AIDS, the CMR
would be expected to have fallen to 37.8; AIDS is likely to lead to
a CMR of 152.9, a fourfold increase. The increase will be more than
three times higher in Botswana and double that expected in Kenya and
Zambia than in the absence of AIDS. Nearly 1/4 of children in Malawi
will die before their 5th birthday, with AIDS contributing nearly
one half of the mortality.
In 2010 in the most severely affected countries in west Africa,
Burkina Faso and Cote d'Ivoire, CMR will be nearly 70% higher. In
Guyana in South America, projected CMR will nearly double, in
Brazil, it will increase by one third; in Thailand, it will increase
by 18%.
DETERIORATION IN CHILD HEALTH DUE TO ORPHANHOOD
Life Expectancy (LE)
AIDS increases IMR and CMR. But its most significant impact on
demographic indicators is on life expectancy since many years of
life will be lost due to the AIDS epidemic. AIDS has already led to
reductions in life expectancy.
By 1996:
Kenya's LE had fallen from 65 (without AIDS) to 55.6 years, to 86%
of that expected without AIDS.
Uganda's LE has fallen from 53.2 to 40.3 years, to 75% of that
expected.
Zimbabwe's LE has fallen from 64.1 to 41.9, to 65% of that expected.
The greatest impact to date has been in Zambia, from 57.5 to 36.3
years, to 63% of that expected without AIDS.
By 2010, life expectancy in Zimbabwe would have reached 70
years without AIDS. As a result of AIDS, projected life expectancy
in Zimbabwe will be 33.1 years, 47% of that expected. Zambia's life
expectancy will fall to 30.3, and Botswana's to 33.4, both 50% of
that expected. Kenya and Uganda's life expectancy will both be about
two thirds of that expected while Malawi's life expectancy of 29.5
years, 52% of that expected without AIDS, will be the lowest in the
world.
Orphanhood
Life expectancy for females will be even lower than these average
figures, since women are HIV-infected and die at younger ages than
men. Lowered life expectancy necessarily implies an increasing
proportion of orphaned children.
I want to present estimates of the orphan epidemic using
projections from Zimbabwe which have been developed by Simon Gregson
at the University of Oxford in association with Prof Roy Anderson's
modelling unit. The first point to note is that the main findings of
this model are in keeping with those of the US Bureau of the Census
(USBC), despite considerable differences in modelling methodology.
Thus, in this model, life expectancy is estimated to be 30-35,
compared to 33.1 in the USBC estimate; fewer than 20% of women can
expect to live throughout their child-bearing years; only one third
of girls aged 15 years will survive to their 35th birthday. And one
third of children under 15 years will be orphans, having lost their
mother.
In order to understand the implications of the orphan epidemic,
we need to have a perspective of 20 or 30 years. The dark part of
this graph represents children who are orphaned due to causes other
than HIV. Before the AIDS epidemic, about 2-3% of children are
orphans; there was relatively little impact of the epidemic upon
maternal orphanhood until the middle years of this decade. Already
it is likely there are more maternal orphans due to AIDS than due to
other causes. But we are right at the beginning of the orphan
epidemic. By the year 2010, the number of maternal orphans is
expected to have increased tenfold due to the cumulative impact of
over 30% of children under 15 years becoming motherless; although no
models have yet incorporated paternal deaths, we know that a large
proportion of these orphans will also be fatherless, double orphans.
Implications of Orphan epidemic
Orphanhood has profound implications for child survivors.
Traditionally the extended family coping mechanism for orphans was
their aunts and uncles. As a result of the AIDS epidemic and rapid
increases in the number of orphans, the very elderly and the very
young are being recruited for childcare by the extended family. Our
study of 300 orphan households in Zimbabwe in 1995 found that nearly
one half of the care givers of paternal or maternal orphans were
grandparents. The average age of grandparent care givers was 62 years
old. About 3% of households were sibling-headed; in three cases,
older sisters or brothers had taken over childcare following the
death of a grandparent.
In a recently completed study of 43 child-headed households, we
found that in 86%, both parents had died and in 93%, the mother had
died; the youngest unaccompanied household was headed by an 11 year-
old child. Older brothers as well as older sisters were involved in
childcare. In many cases, relatives provided support to CHH by
regular visiting and providing material assistance. We must expect
considerable increases in the numbers of CHH in the future,
especially in southern Africa where the epidemic has its most
profound effect on life expectancy and where traditional extended
family coping mechanisms are weakened.
The fact that over one third of children are being looked after
by someone other than their mother has implications for child
health. In child health in developing countries, we rely upon the
mother as the main primary health care worker. We spend time
educating mothers about good child health practices. If a child has
no mother carer, the child's health is often worse. Elderly and very
young care givers may not know about good nutrition. They may not
know about oral rehydration in the treatment of diarrhoea. They may
be unable to travel with the infant to immunisation posts. And they
may be less skillful than mothers at spotting whether a young child
is sick from, for example malaria, which requires travelling with
the child to a clinic to receive curative treatment. Add to this the
fourth wave of the HIV/AIDS epidemic, the twin epidemics of TB and
poverty which follow in the wake of HIV/AIDS and orphanhood and we
see the scale of the disaster being faced by future generations of
children in badly affected countries.
CHALLENGES IN CHILD HEALTH
Ensuring adequate treatment of children with HIV infection will
remain a challenge to front line health workers in the next decade.
But the number of cases of paediatric AIDS will not go on increasing
indefinitely. Already in urban areas there are signs that we are
witnessing a plateau in the number of new cases of HIV infection in
children. Paediatric HIV impact in hospitals may be manageable. However
better data collection on HIV impact on children is required. Recent
cohort studies suggest over 80% of deaths in young adults in Rakai and
Masaka are due to AIDS. No such information is available on children.
To improve child health due to HIV, a number of measures are required.
1. We need to reduce the number of children developing HIV infection.
The most effective method of reducing the number of children
developing HIV infection is to establish programmes which reduce HIV
transmission to mothers. In addition, urgent research into
interventions to reduce mother-child transmission in developing
countries such as vaginal disinfection, vitamin A supplementation,
breast-milk substitution in the first 5 days and after 6 months and
traditional alternatives to breast-feeding.
2. We need to identify measures which prolong HIV-positive mother's
life expectancy
Infants and young children need their mothers to ensure their health
and well-being. Extending the lives of HIV-infected mothers by one or
two years will help to reduce the number of orphaned children being
looked after by alternative caregivers.
3. We need to develop effective low cost community support programmes to
orphans
We are witnessing a rapid increase in the number of orphaned
children who are particularly vulnerable to HIV infection. Orphan
support programmes can help to improve their situation substantially,
by ensuring at-risk households are regularly visited, children's
health is supervised, food supplements and income generating inputs
are provided and primary school enrolment can be maintained.
Regards,
Geoff Foster
---
Dr G. Foster
Family AIDS Caring Trust
Box 970
Mutare, Zimbabwe
e-mail gfoster@healthnet.zw
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